Every finding on record at Guidance Health Care Services Inc

A recertification survey was conducted on 03/19/2025. The census was 0 (Licensed and Certified) and 0 (Licensed Home Health). The agency is in compliance with no violation cited.

A recertification survey was conducted on 03/19/2025. The census was 0 (licensed & certified). Abbreviations: OASIS -outcome and assessment information set CMS- Center for Medicare and Medicaid Services IQIES – Internet Quality Improvement & Evaluation System QR – Quality Review

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on Record review and interview the agency failed to transmit completed OASIS (a tool used by CMS to collect certain patient information) assessment to CMS within 30 days of completing the OASIS assessment, in that: from 09/01/2024 to 03/06/2025 there were 9 assessments transmitted greater than 30 days from the assessment completion date. This Failure prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 9 (patients 1, 2, 4, 5 and 6) assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” On 03/14/2025 at approximately 10:42 AM the surveyor conducted an interview with the Administrator. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 09/01/2024 to 03/06/2025 the agency transmitted 9 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked who was responsible for transmitting the OASIS assessment to CMS. The Administrator stated, “I do” The surveyor asked if the agency tracked how long it took for an OASIS to be transmitted to CMS. The Administrator stated, “I always send them in when I get it done” The surveyor asked why the agency had 9 OASIS assessment that were transmitted past 30 days to CMS. The Administrator stated, “I think we do not get back all the doctors to sign an then we can’t submit them until the doctor sign everything and we get it back to make sure the OASIS is accurate.” The surveyor asked how often the agency transmitted OASIS assessments to CMS. The Administrator stated, “I just submit them when I get them done.” Record review for Patient 1: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64077092 submission date 11/08/2024 with 2 total record processed. Record 1 (Patient 1) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 1) of the OASIS Agency Final Validation report that was submitted on 11/08/2024 had a M0090 completion date of 10/06/2024. Record review for Patient 2: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed two late submissions during record review. The first late submission was identification number 63939840 submission date 10/11/2024 with 1 total record processed. Record 1 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 10/11/2024 had a M0090 completion date of 08/05/2024. The second late submission was identification number 64180774 submission date 12/02/2024 with 2 total records processed. Record 1 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 12/02/2024 had a M0090 completion date of 10/03/2024. Record review for Patient 4: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64104199 submission date 11/14/2024 with 2 total records processed. Record 1 (Patient 4) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 4) of the OASIS Agency Final Validation report that was submitted on 11/14/2024 had a M0090 completion date of 08/29/2024. Record review for Patient 5: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 63915743 submission date 10/07/2024 with 1 total records processed. Record 1 (Patient 5) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 5) of the OASIS Agency Final Validation report that was submitted on 10/07/2024 had a M0090 completion date of 08/01/2024. Record review for Patient 6: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64180774 submission date 12/02/2024 with 2 total records processed. Record 2 (Patient 6) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 2 (Patient 6) of the OASIS Agency Final Validation report that was submitted on 12/02/2024 had a M0090 completion date of 09/12/2024. On 03/19/2025 at approximately 9:15 AM the surveyor conducted an interview with the Administrator. The surveyor discussed the findings from the patient record reviews. The surveyor explained that during record review he found Patients 1, 2, 4, 5 and 6 had OASIS that were transmitted to CMS more than 30 days after the M0090 dates. The surveyor asked why the OASIS were transmitted past 30 days. The Administrator stated, “I think again it is because we do not have everything back from the doctor to make sure the OASIS matches the face to face.” The surveyor asked how the failure to submit the OASIS to CMS within 30 days could effect the clients services. The Administrator stated, “I don’t know if it would do that.” Review of Agency policy titled, “Timelines” with a revision date of 10/25/2024 read in part: “…II. All completed and encoded OASIS data will be transmitted…from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”

Purpose of visit: Recertification Survey. A survey entrance conference was conducted on 4/07/2022 at 2:50 p.m. with the Administrator. Census: Licensed and Certified: 9 Licensed Home Health: 0 Personal Assistance Services: 37 An exit conference was conducted on 4/19/22 at 6:40 p.m. with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within ten (10) days of receipt of the Statement of Deficiencies.

Purpose of visit: Recertification Survey. A survey entrance conference was conducted on 4/07/2022 at 2:50 p.m. with the Administrator. Census: Licensed and Certified: 9 Licensed Home Health: 0 Personal Assistance Services: 37 Abbreviations: BNI – Benefits Notices Initiative NOMNC – Notice of Medicare Non-Coverage QIO – Quality Improvement Organization An exit conference was conducted on 4/19/22 at 6:40 p.m. with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within ten (10) days of receipt of the Statement of Deficiencies.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform the patients of their rights at least two (2) days prior to discharge. The agency failed to inform the patient of their right to appeal the discharge decision in one (Patient #9) of one discharged record review in which the patient was discharged with goals met. This failure placed Client #9 at risk of not being prepared for post-discharge needs, a delay in receiving needed services from another provider and denied them the right to appeal the discharge decision. Findings Include: Clinical Record Patient #9: A review of the agency document titled “Patient Discharge List” indicated Patient #9 was discharged on 09-09-2021. The reason for discharge was listed as “Goals Achieved.” The record did not include evidence which indicated a written notification had been provided to Patient #9 no later than two (2) days prior to the discharge date complete with the name and contact information of the QIO. During an interview on 4-19-2022 at approximately 4:00 p.m., the surveyor reviewed the findings of the record review. The Administrator stated she did not know why Patient #9 was not given notification of the intent to discharge no later than two (2) days prior to discharge. The surveyor asked how this failure could have impacted the client. The Administrator stated she verbally informed the client of the agency’s intent to discharge. The record did not include any evidence or documentation Patient #9 had been given verbal notice of discharge. The surveyor reviewed the agency policy and regulation regarding providing the client with a written notification of discharge no later than two (2) days prior to discharge. On July 1, 2005, the new Medicare regulations (Benefits Improvement and Protection Act) BNI gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by the regulation. The first is a generic notice (Called a Notice Of Medicare Provider Non-Coverage) that the provider will deliver whenever a beneficiary's Medicare coverage of services is ending. The phone number of the QIO should be included in this notice (1-800-725-8339). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the Beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. The agency policy titled “PATIENT/CLIENT TRANSFER AND DISCHARGE NOTICES…PE.6” with a revision date of 08-01-2020 read in part “…PROCEDURE…II. Notice of Medicare Non-Coverage… A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client (or their representative) when providing the five (5) day notice of discharge…” No additional information or documentation was provided to dispute or correct the findings by the end of the survey.